The ANZICS Consensus Statement
ANZICS consensus statement was drafted in 2014 by experts in the field - this statement represents best current practice in Australia and New Zealand.
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It is strongly recommended that you read the statement prior to this station.
Patients undergo tracheostomy insertion for two main reasons:
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Airway maintenance - to relieve upper airway obstruction due to anatomical disruption (surgery, malignancy, trauma) or due to inability to protect the airway
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Prolonged ventilation - actual or anticipated dependence on mechanical ventilation, secretion management or indefinite airway access in traumatic or neurological diseases
The Tracheostomy Kit
The Procedure
Percutaneous dilatational tracheostomy (PDT) was originally described by Ciaglia in 1985, using a modified Seldinger multiple dilator technique [37].
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We endorse the single-graduated dilator technique. Surgical tracheostomy is usually reserved for patients who have contraindication to PDT, such as difficult neck anatomy or neck extension limitations.
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The most common risks associated with PDT are bleeding, hypoxia, loss of airway, damage to surrounding structures (posterior tracheal wall, pneumothorax, pneumomediastinum, surgical emphysema) and misplacement of the cannula or tracheostomy.
Important considerations in preparation and insertion are:
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Consent and timing – this is a semi-elective procedure and as such should be performed following appropriate consent of the patient’s spokesperson, during normal working hours and with appropriate support staff, monitoring and equipment
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Positioning – the patient is placed in a supine position with maximally permitted neck extension, facilitated by interscapular placement of towels or pillow
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Bronchoscopic guidance – use of FB is strongly recommended to identify safe needle insertion into the trachea and confirm guidewire placement, as well as avoiding injury to the posterior tracheal wall
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Standard procedural considerations – general anaesthesia, local anaesthetic with adrenaline, maintenance of a sterile field, and confirmation of positioning with post-procedure care.
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The Wellington ICU Tracheostomy Checklist is a useful tool in preparing for PDT.
Tracheostomy Emergencies
70% of airway emergencies in ICU relate to tracheostomy tubes.
Bedhead signs for patients with a tracheostomy alert the clinician to the presence of an altered airway, and provide a prompt to alter the usual airway management algorithm. This is an example, taken from the UK National Tracheostomy Safety Project.
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Importantly, these signs empower the first responder to remove the tracheostomy tube if it is irreparably blocked or displaced as determined by a straightforward algorithm (the purple box). Standard airway management then takes priority, with re-instrumentation of the stoma an option of last resort (maturation of the stoma, allowing easier re-insertion, takes approximately 7 days).
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Lastly, the signs are colour coded: green alerts the clinician to the presence of a tracheostomy, and therefore the patient retains an upper airway; pink indicates that the patient has had a laryngectomy and therefore airway management must be exclusively performed via the stoma (they have an interrupted upper airway).
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